Six times trapped in the bed rails, then an amputation

An 88-year-old woman with dementia was put behind bed rails without a risk assessment, trapped six times, and lost her leg.

What happened

Barbara Humphreys, 88, had dementia and brittle bone disease. She was admitted to Crosfield House care home in Rhayader, Powys, on 29 July 2018, first for emergency respite, then permanently.

On 3 August a registered nurse employed by the company decided on bed rails. No risk assessment for their safe use was completed, and the rails were never reviewed.

On 2 September she was found on the edge of her bed with her back against the rail. On 6 September her legs were between rail and mattress. On 16 November her right foot was trapped, the calf blue and purple, and two carers had to free it. The GP was asked to see her and decided not to.

On 17 November her foot was trapped again. She was taken to Bronglais Hospital in Aberystwyth, where her right leg was amputated above the knee. She died in hospital.

The outcome

The inquest concluded on 11 July 2019 at Welshpool before Ian Boyes, assistant coroner for South Wales Central. The pathologist found a thrombosis above the constriction, and the coroner recorded natural causes. His Prevention of Future Deaths report, 2019-0246, went to the two companies, Care Inspectorate Wales and NHS Wales, listing seven concerns: mattresses not designed for the beds they were used on, no bed-rail policy, and no training in selecting, fitting and reviewing rails.

An HSE investigation found significant gaps between bed frame, rail and mattress on a number of the home’s beds. Crosfield House admitted health and safety offences and was fined £25,000 with costs at Merthyr Tydfil Magistrates’ Court on 20 January 2021, according to the BBC. The district judge said: “The risk was there for all to see and it was not dealt with.”

What went wrong

Six entrapments over three months produced no review of whether the rails should still have been on the bed. The first was the warning. The sixth put her in an ambulance.

The rails did not match the bed, nobody had been trained to select, fit or review them, and there was no policy to work to. A rail that leaves a gap the width of a limb is a trap, and the assessment that would have measured the gap was never done.

What it teaches

Bed rails are restraint equipment with an engineering failure mode as well as a clinical one. The mattress has to match the bed, the gap has to be measured, the assessment written before the rails go on, and read again the first time someone is trapped.

Six entrapments without a review is the finding that should stop a room.

Questions for the room

She was found trapped on 2 September and five more times. What should the second incident have triggered?
You are the nurse who decided on the rails. What would a proper assessment have said, and who signed it?
The GP declined to see her. What does a home do when a resident needs a decision from outside?

Evidence and limits

Confidence: confirmed. The coroner’s Prevention of Future Deaths report 2019-0246, the County Times report of the inquest and two BBC reports of the HSE case were read. They differ on two points. The report gives the date of death as 28 November 2018 and the County Times gives 20 November, so no date of death is given here. The County Times counts five entrapments and the HSE case as reported counts six; six is used.

No member of staff is named, and none was prosecuted. The company admitted the offences, which is why it is named.

Our restraint reduction training covers mechanical restraint, and the assessment and review that has to sit behind it.

Sources

Reviewed 20 October 2026.